What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

Abstract

Background It has been shown that patient demographics such as age, payer factors such as insurance type, clinical characteristics such as preoperative opioid use, and disease grade but not surgical procedure are associated with revision surgery to treat cubital tunnel syndrome. However, prior studies evaluating factors associated with revision surgery after primary cubital tunnel release have been relatively small and have involved patients from a single institution or included only a single payer. Questions/purposes (1) What percentage of patients who underwent cubital tunnel release underwent revision within 3 years? (2) What factors are associated with revision cubital tunnel release within 3 years of primary cubital tunnel release? Methods We identified all adult patients who underwent primary cubital tunnel release from January 1, 2011, to December 31, 2017, in the New York Statewide Planning and Research Cooperative System database using Current Procedural Terminology codes. We chose this database because it includes all payers and nearly all facilities in a large geographic area where cubital tunnel release may be performed. We used Current Procedural Terminology modifier codes to determine the laterality of primary and revision procedures. The mean age of the cohort overall was 53 ± 14 years, 43% (8490 of 19,683) were women, and 73% (14,308 of 19,683) were non-Hispanic White. The Statewide Planning and Research Cooperative System database organization does not include a listing of all state residents and thus does not allow for censoring of patients who move out of state. All patients were followed for 3 years. We developed a multivariable hierarchical logistic regression model to model factors independently associated with revision cubital tunnel release within 3 years. Key explanatory variables included age, gender, race or ethnicity, insurance, patient residential location, medical comorbidities, concomitant procedures, whether the procedure was unilateral or bilateral, and year. The model also controlled for facility-level random effects to account for the clustering of observations among these entities. Results The risk of revision cubital tunnel release within 3 years of the primary procedure was 0.7% (141 of 19,683). The median time to revision cubital tunnel release was 448 days (interquartile range 210 to 861 days). After controlling for patient-level covariates and facility random effects, and compared with their respective counterparts, the odds of revision surgery were higher for patients with workers compensation insurance (odds ratio 2.14 [95% confidence interval 1.38 to 3.32]; p < 0.001), a simultaneous bilateral index procedure (OR 12.26 [95% CI 5.93 to 25.32]; p < 0.001), and those who underwent submuscular transposition of the ulnar nerve (OR 2.82 [95% CI 1.35 to 5.89]; p = 0.006). The odds of revision surgery were lower with increasing age (OR 0.79 per 10 years [95% CI 0.69 to 0.91]; p < 0.001) and a concomitant carpal tunnel release (OR 0.66 [95% CI 0.44 to 0.98]; p = 0.04). Conclusion The risk of revision cubital tunnel release was low. Surgeons should be cautious when performing simultaneous bilateral cubital tunnel release and when performing submuscular transposition in the setting of primary cubital tunnel release. Patients with workers compensation insurance should be informed they are at increased odds for undergoing subsequent revision cubital tunnel release within 3 years. Future work may seek to better understand whether these same effects are seen in other populations. Future work might also evaluate how these and other factors such as disease severity could affect functional outcomes and the trajectory of recovery. Level of Evidence Level III, therapeutic study.

The Unpredictable Ulnar Nerve—Ulnar Nerve Entrapment from Anatomical, Pathophysiological, and Biopsychosocial Aspects

“…In cases where the nerve is painfully dislocated, it can be treated through one of the described nerve transposition procedures [ 73 , 153 , 154 , 155 ]. A higher risk for revision surgery includes patients with workers’ compensation insurance, previous simultaneous bilateral surgery, a submuscular transposition as a primary procedure, spinal cervical disc herniation, a higher BMI, smoking and alcohol consumption, and pain problems after primary surgery, while the risk is lower among those with a higher age and a concomitant carpal tunnel release [ 153 , 156 , 157 ]. Revision surgery may result in complete or partial recovery, but residual problems, such as paresthesia, are the most frequent symptom, and patients with no improvement are common [ 155 , 158 ].…”

Wrist & Hand

“…This work from Rochester (New York, USA) used big data, and aimed to determine the percentage of patients undergoing revision surgery for cubital tunnel syndrome within three years of primary cubital tunnel release. 4 The authors used the dataset to identify factors associated with the need for revision surgery. The research data were obtained from the New York Statewide Planning and Research Cooperative System database, which covers a large geographical area and includes diverse patient populations and payers.…”

CORR Insights®: What Factors Are Associated With Revision Cubital Tunnel Release Within 3 Years?

“…Advocates of transposition cite the benefits of tension relief and relocation into a healthy tissue bed [6]. The relative efficacy of subcutaneous, intramuscular, and submuscular techniques is controversial, with submuscular potentially offering more "protection," but also a greater potential for perineural scarring [11]-a concern potentially borne out by the findings reported by Schloemann et al [9] in this issue of Clinical Orthopaedics and Related Research ® . In situ release is simpler and quicker, preserving the natural blood supply to the nerve [5], and with endoscopic-assisted techniques or with firm retraction, an extensive release can be performed through a small incision.…”

“…As highlighted in this month's CORR ® , Schloemann et al [9] found that factors affecting the likelihood of undergoing revision cubital tunnel surgery seem to extend beyond the success or failure of the index procedure and must also reflect the patient's eagerness for further treatment, the surgeon's perception that something may have gone wrong with the index procedure, or the surgeon's reluctance to perform additional procedures. For example, patients with workers compensation (secondary gain) and patients who underwent submuscular transposition (a more complex and therefore riskier procedure) were more likely to receive revision surgery, while patients with comorbidities (higher potential for medical complications) were less likely to [9].…”